HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
V-2-019
Topic:
Concurrent Care
Section:
Visits
Effective Date:
December 4, 2017
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

Concurrent care is that care provided to an inpatient in a hospital, long-term acute care hospital, rehabilitation hospital or skilled nursing facility, simultaneously by more than one doctor during a specified period of time.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Concurrent care may be considered medically necessary when ONE of the following indications is met:

  • Two or more separate conditions require the services of two or more doctors; or
  • The severity of a single condition requires the services of two or more doctors for proper management of the patient.

The necessity of each doctor's particular skills will be determined by considering the respective specialties and the diagnosis for which services were provided. If additional information is required to establish medical necessity, hospital records may be requested for review.

These records should:

  1. Document the attending/ordering professional provider’s request for the consultant to see the patient; and
  2. Include sufficient documentation to indicate the medical necessity for each doctor’s professional services.

Services that do not meet the above criteria will be considered not medically necessary.

Concurrent care services for the following reasons are considered not medically necessary:

  • Services that exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
  • Services by one physician duplicating or overlapping those of another provider without recognizable distinction.

Related Policies

Refer to the Table Attachment link for guidelines for concurrent care and examples.


Place of Service: Inpatient



The policy position applies to all commercial lines of business



Links






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.